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Denials on more than one initial IP visit code

  1. #1
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default Denials on more than one initial IP visit code
    Medical Coding Books
    Has anyone else received denials for either the actual admitting physician or a "consulting" from their Medicare carrier? We have received them this week; it appears that the first claim received with 99221-99223 is paid, with or without the AI modifier, and any subsequent ones (again with or without modifier) are denied. We have ones where the first claim in was the admitting; it paid, and consultants denied; we also have a case where the consultant filed first; it paid, and our admitting physician's claim was denied. I think they didn't fix their edits! Of course, they are closed for the day, but we will be calling tomorrow and I'll update the thread. Our carrier is Noridian.
    Thanks,

  2. #2
    Location
    Columbia, MO
    Posts
    12,836
    Default
    The admitting physician is suppose to append the AI modifier .CMS did state that if this was not done then all initial visit levels would most likely not be paid.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    The problem is, the admitting/attending did have the AI attached - it denied; the consultant claim without the AI was received first and paid (this was one instance). In the other, the admitting was the first claim in, paid, and the consultant (without the AI) was denied. For the "old" reason that this had already been paid to another provider. We're calling Noridian today, and I'll post their response.

    Thanks,

  4. #4
    Default
    This doesn't sound good.

    My understanding was the AI was informational only and would not affect the claims processing.

    Are your providers from different specialties?

    Laura, CPC, CPMA, CEMC

  5. #5
    Default
    I am being told by my co-worker's to only attach -AI if there is a consult billed the same day, i disagree because what if a physician from another hospital is called in for a consult, I have no way of knowing this so therefore i think it would be appropriate to attach -AI to all medicare admit code's. I have read these articles over and over but can't find anything stating to add it to all admit codes regardless if a consult was performed or not. Does anyone know if attaching -AI will make reimbursement different to without it ??

  6. #6
    Default
    I just sat thru a webinar by HighmarkMedicare today. They state the AI is informational only and does not affect reimbursement. They also state the admiting provider needs to use it, period, there is nothing that states "only if there are other providers billing that code as well". Because as you stated how would you know, just because they didn't call someone else in on the admit itself doesn't mean they won't tomorrow or the next day or so on.

    The other interesting thing they said is that the inpatient side is the only one it is ok to use more than one initial code. So in the case of obs you have to use 99201-99215.

    I'm not under Highmark but WPS is not giving clear direction so we are listening to what all the other carriers are saying so we at least have something to support what we are doing.

    Laura, CPC, CPMA, CEMC

  7. #7
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    Quote Originally Posted by cmcgarry View Post
    Has anyone else received denials for either the actual admitting physician or a "consulting" from their Medicare carrier? We have received them this week; it appears that the first claim received with 99221-99223 is paid, with or without the AI modifier, and any subsequent ones (again with or without modifier) are denied. We have ones where the first claim in was the admitting; it paid, and consultants denied; we also have a case where the consultant filed first; it paid, and our admitting physician's claim was denied. I think they didn't fix their edits! Of course, they are closed for the day, but we will be calling tomorrow and I'll update the thread. Our carrier is Noridian.
    Thanks,
    Everything is OK now. Turns out that the coder on the one where the admitting was denied (and we had the AI) neglected to also put a -25 modifier on, and the provider did dialysis the same day. On the other, Noridian fixed it with the phone call - and said it wasn't due to the initial code, just a glitch. All of our other claims from both admitting and consultants are going through OK (unless of course something else is wrong with them!!).

    Thanks all!

  8. #8
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default More problems with initial hospital visit denials
    I just heard from some follow up staff that our carrier is having a problem again denying the initial visits even when absolutely nothing is wrong; the admitting has an AI modifier; specialty is internal med. Two days later a pulmonologist is called in for a consult; uses 99223 without a modifier, and the claim denied. We investigated to make sure the patient wasn't in hospice, we didn't also do a bronch, etc - nothing. The carrier was then called, and told us it was because they were the same primary specialty. Of course, pulmonology, endocrinology, rheumatology, and a host of others are IM first. They are aware of the problem, and will reprocess, but only as we call on them. They state they are working on it. The carrier is Noridian. According to them, it's an edit they are trying to fix. I just ask myself - what next??
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  9. #9
    Default
    Are they going to reprocess after they fix it? I sure hope so. Leave it to Medicare.
    Colleen R Cox CPC

  10. Default consult
    We are in Chandler, Az and just got 3 denials for the same reason on three intial hospital visits. I spoke to Noridian and they had not received the claim from the admitting doc with the modifier but they did pay a nephrologist CPT Code 99222 for his consult which got to Medciare on 1/27 and ours arrived on 1/28 and denied. The rep did not tell me they were having an issue just that we could call and down code to subsequent, but if they are having an issue, then I am going to call back and speak to another rep.
    Leslie Resendez, CPC

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